Home Deliveries: Not just for pizza? Robyn Lamar, MD, MPH - - PowerPoint PPT Presentation

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Home Deliveries: Not just for pizza?

Robyn Lamar, MD, MPH Assistant Professor OB GYN, UCSF October 2019

Disclosures: None Not something you see every day Rare but rising?

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LIstening to Mothers in California, 2017 survey

What does the Evidence Tell US?

Why do some women choose home birth? How do they fare? How do their children fare? What factors are critical for safe maternity care?

But first: What exactly is home birth like? Planned Home Birth Basics

• Most attended by midwives
• Comprehensive prenatal care, including ultrasound, is the norm
• Intermittent fetal monitoring is standard
• GBS prophylaxis can be administered
• Midwives bring supplies including emergency medications for

hemorrhage, oxygen tank, IV supplies, etc

• ACNM ( & SF community) standard is for two providers with current NRP

and CPR training to attend the birth

• Lidocaine, suturing available if needed
• Vitamin K, erythromycin can be given

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Part I: What Women Want Women increasingly desire fewer medical interventions in childbirth But intervention rates have risen Many women feel pressured to have interventions

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1 in 12 women experiences harsh treatment during childbirth And rates So why do women choose home birth?

[hint: not about glamor]

Which factors do women cite as most important?

#1: Previous negative experiences with hospital care

• 1. Conflicts between a woman’s belief birth is a natural

process, and the experience of interventions of questionable utility

• 2. Difficulty handling multiple interruptions, meeting

multiple strangers

• 3. Unhappiness with care perceived as disrespectful

Which factors do women cite as most important?

#2: Control & Empowerment

• 1. “I feel competent to make

decisions for myself”

• 2. “I want control over the

things that are done to my body” 13 14 15 16

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Which factors do women cite as most important?

#3: Benefits of the home environment

• 1. Comfortable, peaceful, quiet, familiar
• 2. Support people are invited--changes the power

dynamic

How do women choosing home birth rate their care?

The literature is sparse In the small studies that have looked at this:

• Women report very high satisfaction with their care
• This remains true even in the subset requiring

intrapartum transfer of care, when compared to women planning hospital birth who require escalation

• f intrapartum care

Part II: Safety Outcomes Methodological Challenges

• RCT not feasible
• Multiple challenges in observational studies

○ Selection bias ○ Misclassification (especially planned versus unplanned home births) ○ Choosing the best comparison group ○ Identifying & controlling for all relevant confounders

• Health systems differences make international comparisons challenging

○ Training & experience of home birth providers ○ Established criteria for home birth ○ Integration of health system ○ Transport/physical distances

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How do mothers fare who plan a home birth?

Findings are consistent: they fare better

• Lower rate of cesarean

OR 0.35 (0.27-0.46)

• Lower rate of op vaginal delivery

OR 0.37 (0.24-0.58)

• Lower rate of severe perineal trauma

OR 0.57 (0.40-0.81)

• Lower rate of PPH > 1000ml

OR 0.55 (0.55-0.96)

What Studies tell us this?

Name, year Country Study Design N home N hospital Quality Birthplace in England 2011 UK Prospective cohort 16,810 19,706 High Blix 2012 Norway Retrospective cohort 1,631 16,310 High Bolten 2016 Netherlands Prospective cohort 2,050 1,445 High Davis 2011 New Zealand Comparative descriptive 1,830 11,503 High Haldansdottir 2015 Iceland Retrospective matched cohort 307 921 High Hiraizumi 2013 Japan Retrospective cohort 168 340 Moderate Homer 2014 Australia Retrospective population- based cohort 742 242,936 High Miller 2012 New Zealand Retrospective matched cohort 109 116 Moderate Wiegerinck 2015 Netherlands Retrospective cohort 23,323 29,306 Moderate

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Birthplace in England

• Inclusion criteria:

○ “Healthy women with low risk pregnancies,” defined before labor ○ Attended by an NHS midwife at onset of labor ○ 37 weeks, singleton, live at onset of labor

• Sample: prospective cohort from all NHS trusts providing intrapartum

care at home + a stratified random sample of obstetric units, 2008-2010

• Exposure: planned place of birth at the start of labor
• Analysis: by intention to treat
• Outcomes

○ Primary: composite of perinatal mortality + specific morbidities ○ Secondary: maternal morbidities, interventions, and mode of birth ○ Planned subgroup analysis by parity

Birthplace in England: Key Takeaways for Mothers

aOR (99% CI) Op Vag 0.43 (0.32-0.57) C/s 0.31 (0.23-0.41) Epis 0.33 (0.28-0.39) 3rd/4th 0.77 (0.57-1.05) Transfusion 0.72 (0.47-1.12)

What about US Data? Snowden et al, 2015

• Inclusion criteria: cephalic, singleton, term, nonanomalous
• Sample: population-based, retrospective cohort study of all

births that occurred in Oregon during 2012 and 2013

• Exposure: planned place of birth from birth certificate
• Analysis: by intention to treat
• Outcomes

○ Perinatal mortality and morbidity (low apgars, seizure, ventilator support, NICU admit) ○ Maternal morbidity, interventions, and mode of birth

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Snowden: Key takeaways for Mothers

aOR (95% CI) Op Vag 0.24 (0.17-0.34) C/s 0.18 (0.16-0.22) ICU Admit 1.00 (0.31-3.21) 3rd/4th 0.69 (0.49-0.98) Transfusion 1.91 (1.25-2.93)

How do babies fare in planned home birth? How do babies fare in planned home birth?

Findings are split depending on the study type:

• Registry-based data (mostly from other countries)

Most show no differences in stillbirth, early neonatal death, or NICU admission

• US Birth Certificate data

Higher risk of stillbirth, early neonatal death, seizures, and NICU admission

How do babies fare? US data

• Historic data challenges due to:

○ Fractured health care system ○ Birth certificates didn’t indicate planned place of birth

• Two more recent studies using

new birth certificate data show: ○ Higher perinatal mortality ○ Higher neonatal morbidity 29 30 31 32

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Snowden: Key Takeaways for Babies

aOR (99% CI) Perinatal death 2.43 (1.37 to 4.30) Apgar <4 at 5 minutes 1.75 (1.07-2.86) NICU admit in first week 0.71 (0.55 to 0.92) Neonatal seizure 3.60 (1.36 to 9.50)

Grunebaum et al, 2016

• Inclusion criteria: singleton, term, nonanomalous with birthweight >2.5kg
• Sample: population-based, retrospective cohort study of all births 2009-

2013 in states that used the 2003 revised birth certificate

• Exposure: planned place of birth as indicated on birth certificate
• Outcome: neonatal death (liveborn infant who dies before day 28 of life)
• Analysis by individual risk factors

○ Parity ○ Maternal age ○ Gestational age ○ Presentation ○ Prior cesarean

Grunebaum: Key Takeaways for Babies How do babies fare? Registry-based data

Findings are largely consistent across studies in multiple countries and a variety of study designs: babies fare well

• Same low rate of stillbirth

OR 0.94(0.76-1.17)

• Same low rate of neonatal death

OR 1.00 (0.78-1.27)

• Fewer NICU admissions

OR 0.71 (0.55-0.92) 33 34 35 36

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Name, year Country Study Design N home N hospital Quality Birthplace in England 2011 UK Prospective cohort 16,810 19,706 High Blix 2012 Norway Retrospective cohort 1,631 16,310 High Burns 2012 UK Prospective cohort 2,964 4,130 High Davis 2011 New Zealand Comparative descriptive 1,830 11,503 High De Jonge 2015 Netherlands Retrospective cohort 466,122 276,958 High Haldansdottir 2015 Iceland Retrospective matched cohort 307 921 High Homer 2014 Australia Retrospective population- based cohort 742 242,936 High

Scarf et al: Systematic review & meta-analysis 2018 De Jonge 2015: Key Takeaways for Babies

aOR (99% CI) Nullip Multip Perinatal death 0.99 (0.79– 1.24) 1.16 (0.87– 1.55) Apgar <4 at 5 minutes 0.87 (0.71– 1.07) 0.92 (0.70– 1.20) NICU admit in first week 1.04 (0.91– 1.18) 0.74 (0.62– 0.87) Serious adverse

• utcome*

0.93 (0.84– 1.04) 0.76 (0.66– 0.87)

Birthplace in England: Key Takeaways for Babies

aOR (99% CI) All 1.16 (0.76-1.77) Nullips 1.75 (1.07-2.86) Multips 0.72 (0.41-1.27) Composite outcome includes: Stillbirth, early neonatal death, HIE, mec aspiration syndrome, brachial plexus injury, fractured humerus or clavicle

Hutton et al 2016

• Inclusion criteria:

○ Prenatal care booked with registered midwife in Ontario ○ No more than 1 prior cesarean

• Sample: retrospective cohort of all such pregnancies planning home birth

at start of labor, matched for parity and prior c/s to low risk group planning hospital birth 2006-2009 (N = 11, 493 in each group)

• Exposure: planned place of birth at the start of labor
• Analysis: by intention to treat
• Outcomes

○ Primary: composite of perinatal death, 5 min Apgar < 4; chest compression; PPV ○ Secondary: intrapartum intervention, mode of delivery, maternal morbidity

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Hutton et al 2016: Key Takeaways for Babies

RR (95% CI) Nullip Multip Perinatal death 1.17 (0.39– 3.47) 0.67 (0.11– 3.99) Apgar <4 at 5 minutes 0.67 (0.36– 1.26) 0.75 (0.36– 1.59) PPV & cardiac compressions 1.11 (0.59– 2.10) 0.89 (0.34– 2.30)

How do babies fare? Summarizing the data

• Large, well-designed observational studies in a number
• f other countries (Canada, the Netherlands, England,

Norway, New Zealand) show excellent neonatal

• utcomes for planned home birth
• Large, recent US studies using improved birth certificate

data show higher risk of perinatal mortality for planned home birth (OR ~2-3)

Key take-away for Babies

Planned home birth is not inherently unsafe for babies. However, as it currently exists in the US, it appears riskier than planned hospital birth

What makes home birth safe for babies?

Common themes in countries with good neonatal outcomes in planned home birth:

• Uniform, accepted guidelines defining appropriate

candidates

• Midwives well-trained and integrated into the health system
• Consistent mechanism for midwives to consult or transfer

pts

• High rates of transfer, particularly for nulliparas

○ Birthplace in England: nullips ~40%, multips ~10%

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Home Birth Transfer versus Failed Home Birth Some perspective (data from Snowden) ACOG Committee Opinion: Planned Home Birth

“Although the American College of Obstetricians and Gynecologists believes that hospitals and accredited birth centers are the safest settings for birth, each woman has the right to make a medically informed decision about delivery.” Key safety factors to highlight in counseling:

• appropriate selection of candidates for home birth
• CNM, CM or midwife whose education and licensure meet International

Confederation of Midwives’ Global Standards for Midwifery Education

• ready access to consultation & access to safe and timely transport
• Absolute contraindications: fetal malpresentation, multiple gestation, or

prior cesarean delivery

NICE Guidelines: Low risk women

1.1.1 Explain to both multiparous and nulliparous women who are at low risk of complications that giving birth is generally very safe for both the woman and her baby. 1.1.2 Explain to both multiparous and nulliparous women that they may choose any birth setting (home, freestanding midwifery unit, alongside midwifery unit or obstetric unit), and support them in their choice of setting wherever they choose to give birth: . . . Advise low-risk nulliparous women that planning to give birth in a midwifery-led unit (freestanding or alongside) is particularly suitable for them . . . Explain that if they plan birth at home there is a small increase in the risk of an adverse outcome for the baby. [2014]

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My own thoughts

• US maternity care prioritizes practices perceived as improving safety for

neonates, even when it harms their mothers

• Restrictive OB practices may be driving women out of hospital care

entirely

○ TOLAC ○ Breech ○ Multiples ○ Postterm

• Long campaign to marginalize midwifery continues to impact our

collective imagination about what high quality maternity care looks like.

• “Too little too late” feels more important than “too much too soon.”

Conclusions

• Home birth is rare but may be rising

*Don’t panic* Evidence shows

• Mothers do better with planned home birth
• Babies in the US do worse with planned home birth, but this is not an

inevitability, and the absolute risk difference is small Home birth is safe in other parts of the world, and it could be here, too

THANK YOU!

Citations

• American College of Nurse-Midwives. Midwifery Provision of Home Birth Services: American College of Nurse-Midwives. J

Midwifery Womens Health. 2016 Jan-Feb;61(1):127-33.

• Birthplace in England Collaborative Group. Perinatal and maternal outcomes by planned place of birth for healthy women with

low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011 Nov 23;343:d7400.

• Boucher D, Bennett C, McFarlin B, Freeze R. Staying home to give birth: why women in the United States choose home birth. J Midwifery

Womens Health. 2009 Mar-Apr;54(2):119-26.

• Committee on Obstetric Practice. Committee Opinion No. 697: Planned Home Birth. Obstet Gynecol. 2017 Apr;129(4):e117-e122.
• Janssen PA, Carty EA, Reime B. Satisfaction with planned place of birth among midwifery clients in British Columbia. J

Midwifery Womens Health. 2006 Mar-Apr;51(2):91-7.

• Geerts CC, van Dillen J, Klomp T, Lagro-Janssen ALM, de Jonge A. Satisfaction with caregivers during labour among low risk

women in the Netherlands: the association with planned place of birth and transfer of care during labour. BMC Pregnancy

• Childbirth. 2017 Jul 14;17(1):229.
• Grünebaum A et al.. Planned home births: the need for additional contraindications. Am J Obstet Gynecol. 2017

Apr;216(4):401.e1-401.e8.

• Scarf VL et al. Maternal and perinatal outcomes by planned place of birth among women with low-risk pregnancies in high-

income countries: A systematic review and meta-analysis. Midwifery. 2018 Jul;62:240-255.

• Snowden JM et al. Planned Out-of-Hospital Birth and Birth Outcomes. N Engl J Med. 2015 Dec 31;373(27):2642-53.
• Vedam S, Rossiter C, Homer CSE, Stoll K, Scarf VL. The ResQu Index: A new instrument to appraise the quality of research on

birth place. PLoS One. 2017 Aug 10;12(8):e0182991. doi: 10.1371/journal.pone.0182991

• Zielinski R, Ackerson K, Kane Low L. Planned home birth: benefits, risks, and opportunities. Int J Womens Health. 2015;7:361–377.

Published 2015 Apr 8. doi:10.2147/IJWH.S55561

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